Dentist

Infection Control

The Dental Quality Assurance Commission amended the infection control rules January 23, 2021. The amended and new sections incorporate many of the Centers for Disease Control and Prevention (CDC) recommendations including:

  • Written policies and procedures with annual staff training;
  • Sterilization of low-speed hand piece motors;
  • Sterilization of single use items when appropriate;
  • Storage and wrapped packages, container, or cassette requirements;
  • Identification of appropriate disinfectants;
  • High volume evacuation; and
  • Water line testing.

The rules are effective January 23, 2021. There are two exceptions: sterilization of low-speed hand piece motors, August 31, 2022, and water line testing, December 1, 2021.

WAC 246-817-601 - Purpose

Why are these new rules being implemented?

The Centers for Disease Control and Prevention (CDC) published specific dental health care setting guidelines in 2003 and updated those guidelines with the summary in 2016. The CDC guideline provides a thorough background explaining the guidelines are designed to prevent or reduce potential for disease transmission in a dental health-care setting. The new rules incorporate many of the CDC recommendations.

The Dental Commission initially determined to proceed with rule development on June 3, 2016 after responding to correspondence related to sterilization requirements. A petition for rule-making was received on July 5, 2016 requesting sterilization of low-speed hand piece motors in WAC 246-817-620. The commission evaluated this request and determined the petition for rule-making recommendation would be considered during the collaborative rule making process. Sterilization of low-speed hand piece motors is included in the new rules.

The primary intent of the new rule development is the safety of the citizens of the state of Washington. Antibiotic-resistant bacteria are becoming more common and more dangerous, especially on surfaces or provider/patient skin in dental settings. The new rule development is based on science, research, and best industry practice. As of 2019, 30 state dental boards already require that dental health care providers follow the CDC guidelines; the commission determined that it is reasonable for Washington state-licensed dentists and dental health care providers to follow these well-tested guidelines as requirements for infection control and prevention in the dental practice setting.

https://www.cdc.gov/oralhealth/infectioncontrol/guidelines/.

Do I have to buy the CDC guideline book?

No, it can be downloaded or accessed online free.

Do I need to follow the administrative guidelines as indicated by the CDC?

No, you need to follow the rules in the WAC 246-817-615 - Administrative, education and training. Best practices would include following all the CDC recommendations including administrative guidelines.

WAC 246-817-615 - Administrative, education, and training

What is infection prevention standards education?

WAC 246-817-615 indicates subject criteria the education must include. They are as follows:

  • Precautions and prevention of disease transmission;
  • Prevention of cross-contamination;
  • Practitioner safety and personal protection equipment;
  • Hand hygiene;
  • Respiratory hygiene and cough etiquette;
  • Sharps safety and safe injection practices;
  • Sterilization and disinfection of patient care items and devices;
  • Environmental infection prevention and control;
  • Dental unit water quality; and
  • Current WAC 246-817-601 through 246-817-660 review.
When does training have to be completed by?

After the rules are effective, you must complete one hour of described training annually. You have 12 months to complete the required one-hour training.

May training be completed online?

Yes. The annual training may be completed online or in-person. If one hour of training is completed online, it meets the requirements of the rule. If a dentist uses the one hour of online as part of their dentist license continuing education hours required in WAC 246-817-440, only 30 minutes may be used to meet the dentist license continuing education.

Who is qualified to provide the training?

A qualified individual or organization means a person or entity that has verifiable training, expertise, or experience in all aspects of infection control. It can be an experienced health practitioner, an educator, or an outside organization.

When must I (the dentist) have written policies in place?

A dentist should implement written policies immediately after rules are effective. Written policies can be implemented prior to the rules being effective.

Must a licensed dentist personally develop the written infection prevention policies and procedures?

No. A licensed dentist is responsible to ensure the facility has written infection prevention policies and procedures. The dentist may delegate this to another staff person or hire an outside organization to develop. The dentist must review annually with all staff.

WAC 246-817-640 - Personal protective equipment

When do I need to wear gloves?

Whenever touching items that will go into a patient's mouth or touching items that have been in a patient's mouth. Gloves must be appropriate to the task.

WAC 246-817-645 - Respiratory hygiene and cough etiquette

Why do I have to provide masks to individuals not receiving care?

As a health care practitioner, you should educate others in the importance of infection prevention measures to prevent the spread of respiratory pathogens when in contact with symptomatic individuals.

Where can I obtain appropriate signs about cough etiquette?

The Department of Health and the CDC have free downloadable signs available online. You may obtain signs from other organizations or you can create your own signs.

https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/EmergencyPreparedness/MedicationHealthCareCenters/Signs/CoverYourCough

https://www.cdc.gov/flu/pdf/protect/cdc_cough.pdf

WAC 246-817-655(1) - Sterilization and disinfection, environmental infection prevention and control

When do I have to begin sterilizing (autoclave) my low-speed hand piece motors?

The commission provided 18 months for dentists to comply with this new rule due to the increased cost to purchase additional hand pieces. Sterilization destroys all microorganisms including substantial numbers of resistant bacterial spores. Dentists need to be compliant by August 31, 2022.

Are new low-speed hand piece motors required?

No. Most major-brand low-speed hand piece motors can be sterilized and are recommended to be sterilized according to manufacturer instructions. The sterilization of low-speed hand piece motors becomes mandatory August 31, 2022.

Can my low-speed hand piece motors be autoclaved?

Most major manufacturers recommend autoclaving the motors, the CDC recommends it, and studies show that some motors will last longer with this care. Motors that have been wiped down during use may have their lives shortened because of residual debris left inside and consequent autoclaving.

I have a battery-operated low-speed hand piece motor; does it have to be sterilized?

No. Sterilization is not required for those sections of a battery-operated hand piece system that cannot be sterilized according to manufacturer's instructions. However, battery-operated hand piece systems that have specific engineering controls to isolate the sections that cannot be sterilized, render those sections "noncritical," must be used if commercially available; those sections that cannot be sterilized must be processed according to manufacturer's instructions between patient uses.

What if my hand piece is not described in the rules?

The "low-speed" designation was included in these rules to indicate that now all air-driven hand pieces motors (both high- and low-speed) must be sterilized after use on a patient. All hand pieces, regardless of their power source, must be sterilized (or disinfected if unable to be sterilized) based on the manufacturer's instructions.

How do I know when it is required to sterilize a dental device?

If a device is:

1. FDA approved;

2. Used as intended by the manufacturer; or

3. Not listed in the rule.

Follow the manufacturer's instructions for sterilization. CDC (2003) – For processing any dental device that can be removed from the dental unit air or waterlines, neither surface disinfection nor immersion in chemical germicides is an acceptable method for the following dental devices:

  • High- and low-speed hand pieces (air, electric, and surgical);
  • All hand piece motors;
  • Prophylaxis angles (nosecones and contra-angles);
  • Ultrasonic and sonic scaling tips; and
  • Air and water syringe tips.

CDC (2018) – For cordless FDA-cleared devices, follow manufacturer IFUs.

What dental equipment must I clean and reprocess through disinfection or sterilization?

Equipment is generally defined as any necessary item for a particular purpose. You must clean and reprocess all critical, semi-critical, and non-critical dental equipment, devices, or tools.

If a single-use item is individually packaged, i.e. orthodontic bracket or wire, and is left unopened on the surface, does it still have to be discarded?

No. If a single-use item is individually wrapped, then it has not been exposed to aerosols. The packaging should be disinfected before returning it to the dental inventory.

WAC 246-817-655(2) - Sterilization and disinfection, environmental infection prevention and control

How close to the patient appointment may I open wrapped instruments and supplies?

Opening in the presence of the patient is preferred but the commission recognizes some procedural set-ups take additional time. Opening sterile instruments should be as close to the time of the procedure as possible. Packages should not be opened the night before.

Do I have to bag or wrap an instrument if sterilized for immediate use?

No. Immediate use sterilization, also known as flash sterilization, is not intended for daily sterilization protocol. It should be used only when a critical tool has been contaminated unexpectedly and is needed to complete a procedure.

WAC 246-817-655(5) - Sterilization and disinfection, environmental infection prevention and control

Does the containment device for transporting contaminated items be labeled with a biohazard symbol?

No. Although it is recommended to include a biohazard symbol on your label.

WAC 246-817-655(10) HVE - Sterilization and disinfection, environmental infection prevention and control

What is a high-volume evacuation or HVE device?

HVE devices usually have large, single-bore or multiple openings. It attaches to an evacuation system that draws a large volume of air. HVE is used to decrease the aerosols created by dental clinical situations expected to produce aerosol or spatter. A saliva ejector does not qualify as an HVE device.

Why is high-volume evacuation necessary?

The ultrasonic scaler and the air polisher create small-particle aerosol contamination. Small-particle aerosol contamination could carry pathogenic organisms such as tuberculosis, hepatitis, human immunodeficiency virus, and severe acute respiratory syndrome. Dental aerosols represent an infection hazard due to their contamination with microorganisms and blood. Use high-volume evacuation whenever possible when aerosol or spatter is expected.

WAC 246-817-660 - Dental unit water quality

When do I have to begin testing my water lines?

The commission provided a delay for dentists to comply with this new rule due to the cost associated to testing. Water line testing must begin on or before December 1, 2021.

Why do I need to test my water lines after a change in the plumbing of my office?

If the plumbing supplies water that is exposed to patients, any change in plumbing initiates waterline bacteria tests in five to 10 days and 21 days to 28 days. The tests must be in line with the plumbing change. If there is pooling or a dead end in the plumbing that was not there before, pathogenic bacterial biofilms can form, some quickly and some slowly dependent on the type of bacteria (https://www.cdc.gov/healthywater/other/medical/med_dental.html).

How do I test water lines?

a. Remove hand pieces, attachments, and motors. Wipe water line outlet (syringe tips, hand piece tubing terminals, etc.) with alcohol wipe to avoid external contaminants.

b. Collect an equal amount of water from each sampled outlet in each dental operatory (e.g. if there are two hand piece tubing and two air/water syringes, collect about one-fourth of the water sample from each outlet). A separate mailer envelope and vial must be used for each operatory.

c. Place the vials in the mailer envelopes and mail to testing organization.

d. Results may be received electronically after seven days of incubation.

e. Document the testing. Keep documentation for five years.

Who is authorized to test water samples?

Several organizations or laboratories provide water testing services. Additionally, do-it-yourself kits can be purchased for water testing.

How often do I have to test my water lines?

Follow the manufacturer instructions for monitoring frequency or perform tests quarterly, except when there have been any changes or remedial action to the water lines. See WAC 246-817-660 for details.

Do I have to test water lines if I have sterile bottle water system?

Yes. Sterile bottle water systems and self-contained units must be tested. Sterile bottled water runs through the lines, so these lines must be tested.

Do I follow dental unit manufacturer or water testing company instructions when testing the water delivery system?

The dental unit manufacturer will have water quality monitoring instructions. Follow these instructions for frequency of testing. If the dental unit manufacturer does not have any instruction related to water quality monitoring, you must test quarterly. Additionally, if you using a testing company, it, too, will have instructions on how to provide your water sample to it.

Can a pooled water sample come from all units in one operatory or only lines from a single water bottle?

You can pool up to 10 water lines from one dental unit or combine multiple dental units. Only 10 water lines total with equal parts water from each line can be pooled. If a result is more than 500 colony forming units (CFU/mL), you must take remedial action in all lines that were combined in that pooled sample or retest each line individually to identify if only one line is compromised or multiple lines. Be sure to document the number of lines pooled in the sample.

Additional questions

What should I do if there is an infection control breach in my dental office?

Contact your local county health department to report the incident immediately. Additionally, the Centers for Disease Control and Prevention (CDC) has the following resources.